This widely acclaimed first volume (1885-1933) is now made available in a newly designed format as a companion to the newly published volume 2 (1933-1973).
This biography of the WWI fighter pilot offers “an intimate portrait of the last recipient of the ‘Blue Max’” (Barrett Tillman). One of the most noteworthy German fighter pilots of World War I was Leutnant der Reserve Carl Degelow, whose squadron of mostly black Fokker D.VII fighters posed a formidable threat to some of Britain’s most celebrated air units on the Western Front. Black Fokker Leader, filled with new information and original photos, is based on the author’s research of significant German archival material and documentation, as well as British, French, and Belgian sources, shedding new light on this legendary ace. The biography offers previously unpublished material about Degelow and his comrades: how he was almost court-martialed; how his career was saved by Josef Jacobs; how Degelow helped Willy Rosenstein escape from Nazi Germany; and much more. Also included are new insights into men like Field Marshal Erhard Milch, Degelow’s wing commander in WWI; and V-2 rocket chief Gen. Hans Jeschonnek, a Degelow protégé in 1918.
As bullets whiz by, walls crumble, and explosions throw you to the ground, the battlefield feels more alive and interactive than ever before. In Battlefield 3, players step into the role of the elite U.S. Marines where they will experience heart-pounding missions across diverse locations including Paris, Tehran and New York... Since 2002, EA's series of Battlefield games have set the standard for realism and ambition. And in Autumn 2011, with the global release of the hotly anticipated Battlefield 3, they're raising the bar even higher. Battlefield 3 will be the most authentic, vivid, all-action first person shooter ever. To be published alongside the game, Battlefield 3: The Russian is also best in class - the first time that a games publisher has worked so closely with an internationally bestselling author. Never before has a tie-in book benefitted from this level of collaboration from the creative team behind the game itself. Nor has it been written by a thriller writer with such a strong track record and reputation. Displaying all of McNab's trademark grit, authenticity and insight, Battlefield 3: The Russian is a scorching top-of-the-line military thriller and a heart-stopping race against time. Prepare to be blown away... Andy McNab joined the infantry as a boy soldier. In 1984 he was 'badged' as a member of 22 SAS Regiment and was involved in both covert and overt special operations worldwide. During the Gulf War he commanded Bravo Two Zero, a patrol that, in the words of his commanding officer, 'will remain in regimental history for ever'. Awarded both the Distinguished Conduct Medal (DCM) and Military Medal (MM) during his military career, McNab was the British Army's most highly decorated serving soldier when he finally left the SAS in February 1993. He wrote about his experiences in three books: the phenomenal bestseller Bravo Two Zero, Immediate Action and Seven Troop. He is the author of the bestselling Nick Stone thrillers. Besides his writing work, he lectures to security and intelligence agencies in both the USA and UK. He is a patron of the Help for Heroes campaign.
Once again, new interpretations are presented of some of the most famous architecture of the period. Work by lesser-known architects, whose influence and role have been overlooked by conventional histories of the subject, is discussed. The case study structure allows each example to be discussed and used as a springboard to explore different theoretical approaches. Filled with beautiful photographs, plans and architect's drawings, this is a clear and accessible discussion on a period of architecture that engages many questions still under debate in architecture today.
This book is a comprehensive guide to the evidence, theories, and practical issues associated with recovery from stuttering in early childhood and into adolescence. It examines evidence that stuttering is associated with a range of biological factors — such as genetics — and psychological factors — such as anxiety — and it critically assesses theoretical accounts that attempt to integrate these findings. Written so that it can be used flexibly to meet the demands of courses about stuttering, the book may be used as a text at the undergraduate or graduate level in psychology or speech-language science.
This arresting miscellany is jam-packed with intriguing and enlightening stories, facts, and trivia about all manner of murderers, miscreants, and malcontents. The book reveals incredible tales about criminal gangs around the world, such as the Japanese Yakuza, the L.A. Crips and Bloods, and the Italian Camorra. Plus, there are extensive lists of criminal slang throughout the centuries; an exploration of Russian prison tattoos; a confidence trickster's lexicon; insights into the world's most audacious crimes-like the the ft of the Mona Lisa-and quotes from the criminals themselves, and the cops who chased them. Inside are gritty black-and-white illustrations and revealing portraits of some of society's scariest criminals.
The Routledge Encyclopedia of Second Language Acquisition offers a user-friendly, authoritative survey of terms and constructs that are important to understanding research in second language acquisition (SLA) and its applications. The Encyclopedia is designed for use as a reference tool by students, researchers, teachers and professionals with an interest in SLA. The Encyclopedia has the following features: * 252 alphabetized entries written in an accessible style, including cross references to other related entries in the Encyclopedia and suggestions for further reading * Among these, 9 survey entries that cover the foundational areas of SLA in detail: Development in SLA, Discourse and Pragmatics in SLA, Individual Differences in SLA, Instructed SLA, Language and the Lexicon in SLA, Measuring and Researching SLA, Psycholingustics of SLA, Social and Sociocultural Approaches to SLA, Theoretical Constructs in SLA. * The rest of the entries cover all the major subdisciplines, methodologies and concepts of SLA, from "Accommodation" to the "ZISA project." Written by an international team of specialists, the Routledge Encyclopedia of Second Language Acquisition is an invaluable resource for students and researchers with an academic interest in SLA.
Poiesis brings together archaeological finds, ancient texts and inscriptions, recent scholarly analysis, and the expertise of modern craftsmen to investigate every known facet of Athens' manufacturing activities. Despite the fact that Athenians consumed great quantities of manufactured goods, and around half of the residents of classical Athens can be shown to have been dependent for survival on manufacturing in some form, the subject has been almost completely neglected by historians. The book draws on the analytical techniques of contemporary business economics--supply and demand, competition theory, and risk-return analysis--to explain events and choices. Manufacturing operations are classified in an original framework that explains why certain segments were suited to the sole craftsman and others to teams of slaves, and deduces earnings potential based upon barriers to entry and competitive differentiation. The result is a new and refreshing angle on how Athenian society operated that complements political, military, and literary perspectives, with important and often surprising implications. Among other insights the analysis shows how fragmented industry structures were fundamental to the workings of Athenian democracy by enabling citizens to supplement their income through casual manufacturing activity.
Fully updated to meet the demands of the 21st-century surgeon, Craniofacial, Head and Neck Surgery and Pediatric Plastic Surgery, Volume 3 of Plastic Surgery, 3rd Edition, provides you with the most current knowledge and techniques across your entire field, allowing you to offer every patient the best possible outcome. Access all the state-of-the-art know-how you need to overcome any challenge you may face and exceed your patients’ expectations. Consult this title on your favorite e-reader, conduct rapid searches, and adjust font sizes for optimal readability. Compatible with Kindle®, nook®, and other popular devices. Apply the very latest advances in craniofacial, head, neck, and pediatric plastic surgery and ensure optimal outcomes with evidence-based advice from a diverse collection of world-leading authorities. Purchase this volume individually or own the entire set, with the ability to search across all six volumes online! Master the newest procedures in pediatric plastic surgery, including conjoined twinning. Apply the latest clinical evidence and surgical techniques to facilitate the decision-making process for craniofacial patients, and optimize outcomes in the correction of congenital, oncologic, traumatic, and acquired deformities. Know what to look for and what results you can expect with over 2,000 photographs and illustrations. See how to perform key techniques with 28 surgical videos online. Access the complete, fully searchable contents online, download all the tables and figures, and take advantage of additional content and images at www.expertconsult.com!
The operas of the German composer Richard Wagner had a revolutionary influence on the course of Western music. Unlike most opera composers, Wagner wrote both the libretto and the music for each of his works. He went on to revolutionise the music form through his concept of the Gesamtkunstwerk (total work of art), by which he sought to synthesise the poetic, visual, musical and dramatic arts, with music subsidiary to drama. He achieved these ideas most fully in his epic cycle of operas 'Der Ring des Nibelungen', notable for complex textures, rich harmonies and the elaborate use of leitmotifs. Delphi’s Great Composers Series offers concise illustrated guides to the life and works of our greatest composers. Analysing the masterworks of each composer, these interactive eBooks include links to popular streaming services, allowing you to listen to the pieces of music you are reading about. Evaluating the masterworks of each composer, you will explore the development of their works, tracing how they changed the course of music history. Whether a classical novice or a cultivated connoisseur, this series offers an intriguing overview of the world’s most famous and iconic compositions. This volume presents Wagner’s masterworks in succinct detail, with informative introductions, accompanying illustrations and the usual Delphi bonus features. (Version 1) * Concise and informative overview of Wagner’s masterworks* Learn about the operas that made Wagner a celebrated composer* Links to popular streaming services (free and paid), allowing you to listen to the masterpieces you’re reading about* Features a special ‘Complete Compositions’ section, with an index of Wagner’s complete works and links to streaming services* English translations of the librettos for the major operas, including works appearing for the first time in digital print* A wide selection of the composer’s prose works, including fiction, pioneering essays and Wagner’s celebrated autobiography* Includes Wagner’s letters to Franz Liszt — explore the composer’s personal correspondence* Features six biographies on the great composer — explore Wagner's intriguing musical and personal life Please visit www.delphiclassics.com to browse through our range of exciting eBooks CONTENTS: The MasterworksSymphony in C MajorDas LiebesverbotFaust OvertureRienziDer fliegende HolländerTannhäuserLohengrinDas RhinegoldDie WalküreTristan und IsoldeWesendonck LiederDie Meistersinger von NürnbergSiegfriedSiegfried IdyllGötterdämmerungParsifal Complete CompositionsIndex of Wagner’s Compositions Selected LibrettosDer fliegende HolländerLohengrinDas RhinegoldDie WalküreTristan und IsoldeSiegfriedGötterdämmerungParsifal Selected ProseAutobiographic SketchOn German OperaArt and RevolutionThe Art-Work of the FutureJudaism in MusicA Communication to My FriendsOpera and DramaBeethovenWhat is German?An End in ParisOn ConductingReligion and Art The LettersCorrespondence of Wagner and Liszt The AutobiographyMy Life The BiographiesRichard Wagner: His Life and His Dramas by W. J. HendersonLife of Wagner by Ludwig NohlRichard Wagner, Composer of Operas by John F. RuncimanWagner by Paul RosenfeldWagner as I Knew Him by Ferdinand PraegerRichard Wagner by Rupert Hughes Please visit www.delphiclassics.com to learn more about our wide range of exciting titles
In this tale of grit and glamour, setbacks and comebacks, business and pop culture icon Tommy Hilfiger shares his extraordinary life story for the first time. Few designers have stayed on top of changing trends the way Tommy Hilfiger has. Fewer still have left such an indelible mark on global culture. Since designing his first collection of “classics with a twist” three decades ago, Tommy Hilfiger has been synonymous with all-American style—but his destiny wasn’t always so clear. Growing up one of nine children in a working-class family in Elmira, New York, Tommy suffered from dyslexia, flunked sophomore year of high school, and found himself constantly at odds with his father. Nevertheless, this self-described dreamer had a vision and the relentless will to make it a reality. At eighteen he opened his own clothing store, parlaying his uncanny instinct for style into a budding career as a fashion designer. Through decades of triumph and turmoil, Tommy remained doggedly optimistic. To this day, his approach to commerce is rooted in his positive view of the world. American Dreamer brims with anecdotes that cover Tommy’s years as a club kid and scrappy entrepreneur in 1970s New York as well as unique insights into the exclusive A-list personalities with whom he’s collaborated and interacted, from Mick Jagger and David Bowie to Ralph Lauren and Calvin Klein. But this is more than just a fashion icon’s memoir—it’s a road map for building a brand, both professionally and personally. Tommy takes us behind the scenes of every decision—and every mistake—he’s ever made, offering advice on leadership, business, team-building, and creativity. This is the story of a true American original, told for the first time in his own words, with honesty, humor, and the insatiable appetite for life and style that proves that sometimes you have to dream big to make it big. Praise for American Dreamer “A unique look into the fashion world . . . an honest, straightforward, mostly entertaining autobiography of the man who created a classic yet hip line of clothing.”—Kirkus Reviews “Fashionistas and business gurus alike will glean important lessons from Hilfiger’s rags-to-riches rag-trade story.”—Booklist “Tommy burst onto the fashion scene at the height of hip-hop and was instantly taken up by rappers and rockers alike. Since then, year after year he has been ahead of the curve with his elegant and stylish looks. His creative energy has always been an inspiration to me. He’s really himself in American Dreamer.”—Mick Jagger "In American Dreamer Tommy shows how he has taken the (rock) stars and the (preppy) stripes and come up with a look—and a label—that are recognized globally as being quintessentially American, as well as a brand that constantly keeps time with pop music.”—Anna Wintour “Tommy is an inspiration to many people. American Dreamer shows how he has managed to be successful in business and done so with integrity.”—David Beckham “Tommy is one of the most genuine people I know! In American Dreamer you can feel his passion pour through everything he does: fashion, fatherhood, family, and friendship!”—Alicia Keys “Tommy Hilfiger is an American icon who was able to transcend fashion and blend it with pop culture and take it to a worldwide audience. American Dreamer documents how, unlike any other designer, Tommy was able to tap into music, its subculture, and its influence on society.”—Tommy Mottola
Surgery, 3rd Edition, provides you with the most current knowledge and techniques hand and upper extremity plastic surgery, allowing you to offer every patient the best possible outcome. Access all the state-of-the-art know-how you need to overcome any challenge you may face and exceed your patients' expectations.
In golf, nowhere is the mental strain more apparent that at the closing stages of a major championship. The crowd, absorbed in every shot, conveys the tension to the players, who are also involved in another contest - the mind game. Before missing the most notorious putt in the history of the Open Championship, Doug Sanders was already thinking of which side of the gallery he would turn to first to acknowledge the applause. When he missed a three foot putt that would have won him the old silver claret jug, there was no applause. Instead people reacted as if they had just witnessed a terrible accident - which, in a sporting context they had. It was Jack Nicklaus, rather than Sanders, who went for the jugular and, in the process, took possession of the jug. The line between victor and victim can be measured not only in millions of dollars but also in fractions of inches. `One minute you're on cloud nine, ' Sam Snead remarked
Fully updated to meet the demands of the 21st-century surgeon, Plastic Surgery provides you with all the most current knowledge and techniques across your entire field, allowing you to offer every patient the best possible outcome. Edited by Drs. Mathes and Hentz in its last edition, this six-volume plastic surgery reference now features new expert leadership, a new organization, new online features, and a vast collection of new information - delivering all the state-of-the-art know-how you need to overcome any challenge you may face. Renowned authorities provide evidence-based guidance to help you make the best clinical decisions, get the best results from each procedure, avoid complications, and exceed your patients’ expectations. Consult this title on your favorite e-reader, conduct rapid searches, and adjust font sizes for optimal readability. Compatible with Kindle®, nook®, and other popular devices. Apply the very latest advances in every area of plastic surgery and ensure optimal outcomes with evidence-based advice from a diverse collection of world-leading authorities. Master the latest on stem cell therapy, tissue engineering, and inductive therapies • aesthetic surgical techniques and nonsurgical treatments • conjoined twin separation and other craniofacial surgery advances • microsurgical lymphatic reconstruction, super microsurgery, and sternal fixation • autologous lipofilling of the breast • nerve transfers in hand surgery, hand allotransplantation, and functional prosthetics • and much, much more. Easily find the answers you need with a new organization that features separate volumes covering Principles • Aesthetic • Craniofacial, Head and Neck Surgery • Lower Extremity, Trunk and Burns • Breast • and Hand and Upper Extremity, plus a more templated, user-friendly, high-yield presentation. Visualize procedures more clearly through an abundance of completely redrawn full-color illustrations and new color clinical photographs. Access the complete, fully searchable contents of each volume online, download all the tables and figures, view 160 procedural videos, and take advantage of additional content and images at www.expertconsult.com!
This book shows how, in his enormously influential 'Essay concerning Human Understanding' (1689), John Locke embraces the new rhetoric of seventeenth-century natrual philosophy, adopting the strategies of his scientific contemporaries to create a highly original natural history of the human mind. With the help of Locke's notebooks, letters and journals, Peter Walmsley reconstructs Locke's scientific career, including his early work with the chemist Robert Boyle and the physician Thomas Sydenham. He also shows how the 'Essay' embodies in its form and language many of the preoccupations of the science of its day, from the emerging discourses of experimentation and empirical taxonomy to developments in embryology and the history of trades. The result is a new reading of Locke, one that shows both his brilliance as a writer and his originality in turning to science to effect a radical reinvention of the study of the mind.
The undisputed gold standard text in the field, Ryan's Retina is your award-winning choice for the most current, authoritative information on new technologies, surgical approaches, scientific advances and diagnostic and therapeutic options for retinal diseases and disorders. Packed with timely updates throughout, new illustrations, and a dedicated team of editors who extend Dr. Ryan’s legacy in retina, this outstanding 6th Edition is a must-have reference for retinal specialists, ophthalmologists, and fellows in training. Offers the most comprehensive content available on retina, balancing the latest scientific research and clinical correlations, covering everything you need to know on retinal diagnosis, treatment, development, structure, function, and pathophysiology. Provides a truly global perspective from five highly esteemed section editors and more than 350 other world authorities from across Europe, Asia, Australasia, and the Americas. Bullets Includes new chapters on widefield imaging, intraoperative OCT imaging, medical management of diabetes mellitus and age-related macular degeneration, and senile retinoschisis. Includes more than 1,150 brand-new illustrations, scans, and photographs throughout. Covers the explosion of new imaging options across optical coherence tomography (OCT), fundus imaging, and autofluorescence imaging, including a greatly expanded OCT imaging chapter that features crucial information on OCT-Angiography (OCT-A). Presents new pharmacotherapy data and the latest approaches in anti-VEGF therapy for age-related macular degeneration, diabetic retinopathy, and venous occlusive disease. Contains thorough content updates in every area of retina, including advanced imaging technologies, gene therapy, inflammation and immune responses, white dot syndromes, epigenetic mechanisms, transplantation frontiers to improve retinal function, macular hole, myopic eye disease, ocular trauma, drug delivery to the posterior segment, advances in macular surgery, vitrectomy and complex retinal detachment, tumors, and retinal genetics and biology.
Completely revised to meet the demands of today's trainee and practicing plastic surgeon, Craniofacial, Head and Neck Surgery Pediatric Plastic Surgery, Volume 3 of Plastic Surgery, 4th Edition, features new full-color clinical photos, dynamic videos, and authoritative coverage of hot topics in the field. Editor-narrated PowerPoint presentations offer a step-by-step audio-visual walkthrough of techniques and procedures in plastic surgery. - Offers evidence-based advice from a diverse collection of experts to help you apply the very latest advances in craniofacial, head and neck, and pediatric plastic surgery and ensure optimal outcomes. - Provides updated coverage of: Aesthetic reconstruction of the nose; Orbito-maxillary reconstruction; Cheek and lip reconstruction; Facial paralysis; Facial transplant; and Surgical management of migraine headaches. - Highlights the latest information on Computerised surgical planning in orthognathic surgery; Computerised surgical planning in craniofacial, head and neck surgery; and Rotation advancement. - Includes brand-new color clinical photos, videos, and lectures. - Expert Consult eBook version included with purchase. This enhanced eBook experience allows you to search all of the text, figures, images, videos, and references from the book on a variety of devices.
Australians have been involved in more conflicts as peacekeepers than as belligerents. This is a part of our history which every Australian citizen, and every school child, should know. Other People's Wars is the first book to tell the whole story of Australia's peacekeeping activities, from the four military observers Australia sent to Java in 1947 to our current deployment in the Solomons. Drawing on years of research in archives, visits to operations in the field, and interviews with peacekeepers, Peter Londey has written an account of our peacekeeping history which is at once both encyclopaedic and readable. Every Australian peacekeeping operation is here, with incisive accounts of the causes of the conflict, the aims of the multinational intervention, the Australian contribution, and the story of what happened. The book treats United Nations and non-UN operations alike and as well as describing the role of the military, it gives full coverage to missions where Australia sent civilian police. Other People's Wars highlights the diversity of Australia's peacekeepers: military observers tramping up mountains in Kashmir, or being shot at in Jerusalem; helicopters in the Sinai, RAN ships in the Persian Gulf; Army engineers in Namibia, doctors in Rwanda, signallers in Cambodia, infantry in Somalia and East Timor; civilian police in Cyprus and civilian peace monitors on Bougainville.
In 1952, Harry Markowitz published "Portfolio Selection," a paper which revolutionized modern investment theory and practice. The paper proposed that, in selecting investments, the investor should consider both expected return and variability of return on the portfolio as a whole. Portfolios that minimized variance for a given expected return were demonstrated to be the most efficient. Markowitz formulated the full solution of the general mean-variance efficient set problem in 1956 and presented it in the appendix to his 1959 book, Portfolio Selection. Though certain special cases of the general model have become widely known, both in academia and among managers of large institutional portfolios, the characteristics of the general solution were not presented in finance books for students at any level. And although the results of the general solution are used in a few advanced portfolio optimization programs, the solution to the general problem should not be seen merely as a computing procedure. It is a body of propositions and formulas concerning the shapes and properties of mean-variance efficient sets with implications for financial theory and practice beyond those of widely known cases. The purpose of the present book, originally published in 1987, is to present a comprehensive and accessible account of the general mean-variance portfolio analysis, and to illustrate its usefulness in the practice of portfolio management and the theory of capital markets. The portfolio selection program in Part IV of the 1987 edition has been updated and contains exercises and solutions.
From Albert Fish to Jeffery Dahmer, these cannibals represent the most horrific parts of the human psyche. This text provides psychology students with in-depth examinations by professionals of the factors that create, motivate, and often lead to the capture of these savage killers. Readers can also take a personality disorder self-assessment quiz to learn more about psychopathythe most common psychological condition for serial killers.
Spinal dysraphism (SD) is a congenital malformation that to a varying extent, often severely, affects the life of the child and the family. Most individuals with SD suffer from neurogenic bladder and bowel dysfunction—with the risk of urinary tract infections, renal deterioration, urinary and fecal incontinence—that affects social participation and quality of life negatively. In newborns with SD, early detection of neurogenic bladder dysfunction and determination of post-void residual urine are required to determine the need of clean intermittent catheterization (CIC) and follow-up. The non-invasive method of four-hour voiding observation with provocation test (VOP) was used to evaluate bladder function in 50 newborn children with SD. Voiding patterns for the children were described and compared with those of 50 healthy newborns evaluated with VOP in an earlier study. Comparison revealed significant differences among several variables. In particular, leakage at provocation test and not voiding with a stream were common in newborns with SD but did not occur in healthy newborns. VOP is a non-invasive standardized method to determine residual urine in newborns with SD. It also adds information on voiding pattern, frequency, voiding with a stream and leakage at provocation. Findings in neonatal VOP of the same cohort of newborns with SD were then related to radiology, presence of urinary tract infections during the first year, and urodynamic findings and use of CIC at the age of one year. It was found that, in children with SD, not voiding with a stream may have a predictive value for the need of CIC at the age of one year, followed probably by lifelong CIC. Despite this, the presence of an open SD per se has stronger predictive value, and each child needs to be evaluated individually while considering a number of factors. The main value of VOP may be as a structured non-invasive screening method to uncover neurogenic bladder-sphincter dysfunction in the newborn. Studies with a larger number of subjects than the present are needed to evaluate the potential of VOP in newborns with closed spinal dysraphism in whom the neurological consequences vary. A retrospective analysis detected renal damage on DMSA scintigraphy in 5 of 41 children with SD who were followed according to a proactive national program with minimal use of surgery. Median follow-up time was 10 years. High baseline pressure was confirmed as a risk factor for renal damage. Compliance with treatment and follow-up is likely to be an important factor for renal health. Therefore, efforts to support children and their families are crucial. A questionnaire-based study of 107 children with SD (age 6–16y) in Sweden and Norway examined aspects of treatment for neurogenic bowel dysfunction focusing on incontinence, independence, general satisfaction and quality of life. It was found that transanal irrigation (TAI) and antegrade colonic enemas (ACE) are effective treatments, but are time-consuming and difficult to perform independently. The majority of children using TAI (72%) and ACE (63%) never went to the toilet alone to empty their bowels. As children achieving independence on the toilet reported higher quality of life, efforts to support independence are beneficial. Continent, self-managing children with healthy kidneys enjoy high quality of life and contribute more fully to society. Therefore, further research is required to investigate and develop existing and new technologies and methods that mitigate the problems related to SD, and to make them accessible to all children with spinal dysraphism. Under de senaste 50 åren har det skett en enastående utveckling av möjligheterna för barn som föds med ryggmärgsbråck. Tidigare har majoriteten av barn med ryggmärgsbråck avlidit redan som spädbarn men idag överlever de flesta till vuxen ålder. Utan aktiva insatser och uppföljning är dock risken för medicinska problem och allvarlig påverkan på livet mycket stor. Nu när nästan alla barn överlever ligger fokus på att också nå okad livskvalitet och självständighet för personer med ryggmärgsbråck. Nästan alla med ryggmärgsbråck måste hantera en allvarlig påverkan på blåsan och tarmen med risk för njurskador, inkontinens och förstoppning. I avhandlingens två första studier värderade vi en metod att, med minimalt obehag för barnet, bedöma blåsfunktionen. Detta för att kunna skilja ut de barn som behöver genomgå mer avancerade undersökningar och få hjälp med blåstömningen genom täta tappningar med kateter, sa kallad ren intermittent kateterisering, RIK. När vi jämförde resultatet av testet för 50 nyfödda med ryggmärgsbråck med samma undersökning av 50 friska nyfödda fann vi stora skillnader. Mest tydligt var att de flesta nyfödda med ryggmärgsbråck (69%) men inga friska nyfödda läckte urin när man tryckte över blåsan. Av nyfödda med ryggmärgsbråck kissade de flesta (74%) inte med stråle vilket alla friska nyfödda gjorde. Att inte kissa med stråle talade också starkt för att barnet skulle komma att behöva hjälp med RIK för att tomma blåsan vid ett ars ålder, och då sannolikt livet ut. Sammantaget visade avhandlingens två första arbeten att den metod för bedömning av blåsfunktion vi undersökt kan användas för att styra uppföljning och behandling av nyfödda med ryggmärgsbråck. Avhandlingens tredje studie visade att aktiv uppföljning av barnen enligt ett nationellt vårdprogram lyckades förhindra njurskador hos de flesta, men att höga tryck i urinblåsan och återkommande urinvägsinfektioner ökade risken för skador. Även familjernas förmåga att i en pressad vardag klara av att genomföra de ofta krävande behandlingar och undersökningar som rekommenderas verkade vara viktig för att förhindra njurskador. Stöttning av familjerna är därför viktig. Avhandlingens fjärde arbete berörde tarmen som nästan alltid är påverkad vid ryggmärgsbråck, med risk för svår förstoppning och avföringsläckage. Detta har påtaglig påverkan på barnen och deras familjer. En tredjedel av de 107 familjerna i vår enkätundersökning i Sverige och Norge (barn 6-16 år) beskrev att man fått avstå från aktiviteter såsom resor på grund av barnets tarmproblem och de barn som hade avföringsläckage rapporterade tydligt lägre livskvalitet än andra. Trots denna allvarliga påverkan finns det hittills inga studier som jämför de olika behandlingar som barnet kan använda. I vår enkät kartlade vi därför vilka metoder som användes och hur bra de fungerade. Vi ställde frågor till både barn och föräldrar, särskilt om avföringsläckage, hur nöjd man var med metoden, barnens livskvalitet och självständighet på toaletten. Det var utifrån svaren tydligt att båda de vanligaste typerna av tarmsköljning var effektiva men tidskrävande och svara för barn och ungdomar att klara att utföra på egen hand. Ingen metod visade sig överlägsen den andra men de barn som klarade att skota tarmtomningen själva skattade sin livskvalitet klart högre än övriga. Vi drar därför slutsatsen att det är viktigt att vårdpersonal diskuterar de olika behandlingsalternativen med barn och föräldrar, och tillsammans med dem väljer den metod som passar det enskilda barnet bäst. Då skapas bästa förutsättningar för att gemensamt arbeta vidare för att uppnå största möjliga självständighet. Självständiga individer, med friska njurar och utan urin- och avföringsinkontinens upplever högre livskvalitet och behöver mindre sjukvård och andra samhällsinsatser. Det behövs mer forskning för att utveckla existerande och nya metoder att hantera de allvarliga komplikationer som riskerar att drabba barn och vuxna med ryggmärgsbråck.
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